Environmental Risk Factors Can Reduce Axial Length Elongation and Myopia Incidence in 6- to 9-Year-Old Children

  • The purpose of this study is to identify risk factors for axial length (AL) elongation and incident school myopia.

  • The design is a Population-based prospective birth-cohort study.

  • Participants included four thousand seven hundred thirty-four (4,734) children examined at 6 and 9 years of age from the Generation R Study in Rotterdam, The Netherlands.

  • Axial length and corneal radius (CR) were measured with an IOLMaster 500 and daily life activities and demographic characteristics were obtained by questionnaire. 

  • Three thousand three hundred sixty-two children (71%) were eligible for cycloplegic refractive error measurements. 

  • Linear regression models on AL elongation were used to create a risk score based on the regression coefficients resulting from environmental and ocular factors. 

  • The predictive value of the prediction score for myopia (≤-0.5 diopter) was estimated using receiver operating characteristic curves. To test if regression coefficients differed for baseline AL-to-CR ratio, interaction terms were calculated with baseline AL-to-CR ratio and environmental factors.

  • From 6 to 9 years of age, average AL elongation was 0.21±0.009 mm/year and myopia developed in 223 of 2136 children (10.4%), leading to a myopia prevalence at 9 years of age of 12.0%. Seven parameters were associated independently (P < 0.05) with faster AL elongation: parental myopia, 1 or more books read per week, time spent reading, no participation in sports, non-European ethnicity, less time spent outdoors, and baseline AL-to-CR ratio. 

  • The discriminative accuracy for incident myopia based on these risk factors was 0.78. Axial length-to-CR ratio at baseline showed statistically significant interaction with number of books read per week (P < 0.01) and parental myopia (P < 0.01). Almost all predictors showed the highest association with AL elongation in the highest quartile of AL-to-CR ratio; incidental myopia in this group was 24% (124/513).

  • Determination of a risk score can help to identify school children at high risk of myopia. Our results suggest that behavioral changes can offer protection particularly in these children.

Publication date

July 1, 2021



Sponsor Institution



Tideman JWL, Polling JR, Jaddoe VWV, Vingerling JR, Klaver CCW
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